1 Consensus statements for cochlear implantation Category 7 Cost implications of CIs 1 Delphi Consensus Group on Cochlear Implantation in Adults Craig A Buchman René H Gifford ID: 934519
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STANDARD OF CARE Systematic review and consensus: unilateral cochlear implants for bilateral severe, profound, or moderate sloping to profound sensorineural hearing loss1Consensus statements for cochlear implantationCategory 7 - Cost implications of CIs
1
Delphi Consensus Group on Cochlear Implantation in Adults
;
Craig A Buchman,
René H Gifford,
David Haynes,
Thomas Lenarz, Gerard O’Donoghue,
Oliver Adunka,
Allison Biever,
Robert Briggs,
Matthew L Carlson, Pu Dai, Colin Driscoll,
Howard W Francis,
Bruce Gantz,
Richard K Gurgel,
Marlan Hansen,
Meredith Holcomb,
Eva Karltorp,
Milind Kirtane,
Jannine Larky,
Emmanuel Mylanus, J Thomas Roland Jr, Shakeel R Saeed,
Henryk Skarzynski,
Piotr H Skarzynski,
Mark Syms, Holly Teagle, Paul Van de Heyning,
Christophe Vincent, Hao Wu,
Tatsuya Yamasoba, Terry Zwolan
.
Slide2Consensus Statement Categories 2Level of awareness of CIsBest practice clinical pathway for diagnosisBest practice guidelines for surgeryClinical effectiveness of CIsFactors associated with post-implantation outcomes
The relationship between hearing loss and depression, cognition and dementia
Cost implications of CIs
Slide3Consensus Statement320. Unilateral cochlear implantation in adults is cost-effective when compared with no implant or no intervention at all and is associated with increased employment and income.11Delphi Consensus Group on Cochlear Implantation in Adults.
Slide4FindingsWhat did the systematic literature review tell us?4
Slide5What is Quality-Adjusted-Life-Years (QALY)?Approach for estimating quality of life benefits in economic evaluationsHealth is measured in utilities0 = Death1 = Perfect healthThe amount of time an individual spends in a given health state is then multiplied by the health state preference value to calculate the Quality Adjusted Life Years (QALY)s gained1 QALY = 1 year of life in perfect healthExample; Quality of life: Significant improvements were reported post CI, in ability to communicate, self esteem, activities and social functioning5Klop WM, Boermans PP, Ferrier MB, Van Den Hout WB, Stiggelbout AM, Frijns JHM. Clinical relevance of quality of life outcome in cochlear implantation in postlingually deafened adults. Otol Neurotol 2008
Slide6Statement 20: Unilateral cochlear implantation in adults is cost-effective when compared with no implant or no intervention at all and is associated with increased employment and income.62 studies reported the incremental cost-effectiveness ratios for unilateral implants versus no implant or no intervention.*,** Increments ranged from:£11,440 to £17,625 (i.e. US$27,250 - 41,983 at 2017 prices) per QALY in the UK healthcare system†€17,100 to €22,500 (i.e. US$25,190 - 33,144 at 2017 prices) per QALY in a Dutch study*1 study demonstrated both an increase in employment rate and median income following unilateral CI in adults. *QALY: Quality of life years *Klop WM, Boermans PP, Ferrier MB, Van Den Hout WB, Stiggelbout AM, Frijns JHM. Clinical relevance of quality of life outcome in cochlear implantation in postlingually deafened adults. Otol Neurotol 2008
**Bond M, Mealing S, Anderson R, Elston J, Weiner G, Taylor RS, et al. The effectiveness and cost-effectiveness of cochlear implants for severe to profound deafness in children and adults: a systematic review and economic model. Health Technol Assess 2009. †
Monteiro E, Shipp D, Chen J, Nedzelski J, Lin V. Cochlear implantation: a personal and societal economic perspective examining the effects of cochlear implantation on personal income. J Otolaryngol Head Neck Surg 2012.
Slide7Supporting Evidence: Klop et al 2008Objective: 10 -Evaluate Quality of life (QoL) benefits after CI (HUI2 and NCIQ)20 -Describe the clinical relevance of cochlear implantation in Health related Quality of life (HRQoL) items using effect size (ES) and minimal clinically important difference (MID) Method: Prospective intervention study in 30 referral hospital. N=44 CI-adults with > 12 months CI-experience. Scores for speech recognition and quality of life measured and compared at preimplant (HAs) and post-implant (CI). Correlations with patient factors were examined.Measures used: at preimplant and postimplant intervals 21, 42, 12 and 241 monthsDutch CVC word lists Health Utility Index Mark II (HUI2) Time trade-off scores (TTO)Nijmegen Cochlear Implant Questionnaire (NCIQ)7Klop WM, Boermans PP, Ferrier MB, Van Den Hout WB, Stiggelbout AM, Frijns JHM. Clinical relevance of quality of life outcome in cochlear implantation in postlingually deafened adults. Otol Neurotol 2008
Slide8Large effectNo effect
Medium effect
small effect
Supporting Evidence:
Klop et al 2008
Results:
Post-implant, significant improvements in group scores (
p<0.001)
compared to preimplant for:
CI is associated with a significant increase in health utility measured by HUI2 and time trade-off (TTO) Educational level, age at implant and duration of loss correlated with one or more outcome measures
8Conclusion: Patients had significant improvements in hearing and communication, self-esteem, daily activities, and social functioning. Statistically significant improvements were also clinically relevant (via MID and ES). Important predictors of outcomes are, duration of deafness and educational level.Klop WM, Boermans PP, Ferrier MB, Van Den Hout WB, Stiggelbout AM, Frijns JHM. Clinical relevance of quality of life outcome in cochlear implantation in postlingually deafened adults. Otol Neurotol 2008 Graph sourced from data on estimations of clinical relevance. Size represents MID %
Slide9Supporting Evidence: Klop et al 20089QOL : Quality of Life; HUI: Health Utilities Index; TTO: Time trade-off Conclusion: Cochlear Implantation (CI) is a cost-effective intervention!
CI significantly improves quality of life and hearing ability for daily activities
Klop WM, Boermans PP, Ferrier MB, Van Den Hout WB, Stiggelbout AM, Frijns JHM. Clinical relevance of quality of life outcome in cochlear implantation in postlingually deafened adults. Otol Neurotol 2008 Utilities: Cochlear implantation showed significant increase in utility measured by HUI2 and TTO.Gain in utility (HUI2): 0.18 (95% CI: 0.13-0.23)Gain in utility (TTO): 0.24 (95% CI: 0.14-0.34)QALYsGain in QALY: 3.3 QALY (according to HUI2)
Gain in QALY: 4.3 QALY (according to TTO)
Cost-utility ratios:
€17,100 to €22,500 per QALY.
(i.e. US$25,190 - 33,144 at 2017 prices)
Slide10Supporting Evidence: Monteiro et al 2012Objective: To determine the economic impact of profound deafness, in terms of employment and income, and subsequent effects of unilateral cochlear implantation.Method: Retrospective analysis of a prospectively collected cochlear implantation database. N=702 adults (> 18 yrs) retrospectively implanted and prospectively surveyed. Changes in employment were assessed before and after implant. 10Monteiro E, Shipp D, Chen J, Nedzelski J, Lin V. Cochlear implantation: a personal and societal economic perspective examining the effects of cochlear implantation on personal income. J Otolaryngol Head Neck Surg 2012.
Slide11Results; More than 50% of subjects reported positive change in employment status post implantation. Of the 50%, 80% attributed the positive change in employment status to their cochlear implant Conclusion; Unemployment rate following implantation decreased to 4.9% from 6.1% at the initial assessment. 11Monteiro E, Shipp D, Chen J, Nedzelski J, Lin V. Cochlear implantation: a personal and societal economic perspective examining the effects of cochlear implantation on personal income. J Otolaryngol Head Neck Surg 2012.Supporting Evidence: Monteiro et al 2012
Comparison of both groups using the Wilcoxon signed rank test revealed a significant difference favouring a higher median income following implantation (p = 0.007). CDN$ Canadian $.
Slide12Supporting Evidence: Bond et al 2009Objective: To investigate whether it is clinically effective and cost-effective to provide a unilateral cochlear implant for adults with severe to profound sensorineural hearing loss deafness (SNHL) who do or do not use hearing aids over their life-time post-implant.Method: Systematic literature review. 24 studies identified, 14 selected. PenTAG cost–utility model for analysis of cost-effectiveness undertaken for identified studies collectively. A mean implant age of 50 years was assumed for adult cohorts.Notes: The PenTAG cost–utility model used a life-time horizon A state-transition model representing the main care pathways of deaf individuals was developed that includes possible complications and device failures. (Failure rates were assumed to be the same across CI-manufacturers) Costs and benefits were discounted at a rate of 3.5% per annum12Bond M, Mealing S, Anderson R, Elston J, Weiner G, Taylor RS, et al. The effectiveness and cost-effectiveness of cochlear implants for severe to profound deafness in children and adults: a systematic review and economic model. Health Technol Assess 2009
Slide13For post-lingually deaf adults with profound SNHL: Unilateral cochlear implantation compared to the best standard of care provides an additional; Unilateral cochlear implantation compared to the preimplant condition for traditional candidates provides benefits in Quality of Life (QoL) measured via the Health Utilities Index mark III (HUI3) of; CostsQALYsIncremental costsIncremental QALYsICER(/QALY)No CI use2488.2---Unliteral CI use34,20710.6
33,9592.414,163
ICER, Incremental cost effectiveness ratioSupporting Evidence: Bond et al 200913
Discounted base-case cost-effectiveness per patient for unilateral CI in adults > 50 years versus no CI
2.4 QALY
giving an
ICER
of
£14,163 per QALY
0.22 (95% CI 0.19–0.24)Bond M, Mealing S, Anderson R, Elston J, Weiner G, Taylor RS, et al. The effectiveness and cost-effectiveness of cochlear implants for severe to profound deafness in children and adults: a systematic review and economic model. Health Technol Assess 2009
Slide14Supporting Evidence: Bond et al 2009Results: Group speech recognition scores demonstrated benefits from CI vs HAs.Adults deafened postlingually had greater benefit than prelingually deafened adults (mean change scores: 62% vs 20%). Improvement in quality of life gains (HUI-3) was:0.22 (95% CI 0.19 - 0.24) for traditional CI-candidates 0.15 (95% CI 0.11- 0.19) for marginal HA-users
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Conclusion: In individual studies and in a new pooled model, unilateral cochlear implants were demonstrated to be cost-effective compared with no interventionBond M, Mealing S, Anderson R, Elston J, Weiner G, Taylor RS, et al. The effectiveness and cost-effectiveness of cochlear implants for severe to profound deafness in children and adults: a systematic review and economic model. Health Technol Assess 2009
Slide1515Unilateral CI in adults versus no implants proved to be cost-effective at the willingness to pay threshold of £30,000 per QALYCI is associated with positive impacts on health- related QoL and improved speech recognition scores
CI is cost effective, significantly improving QoL
and hearing capacityCI is an economically favourable option for patients Median yearly income increased post-implant compared to preimplantEmployment rates increased post-implantTakeaways
Slide16BibliographyBond M, Mealing S, Anderson R, Elston J, Weiner G, Taylor RS, et al. The effectiveness and cost-effectiveness of cochlear implants for severe to profound deafness in children and adults: a systematic review and economic model. Health Technol Assess 2009 Klop WM, Boermans PP, Ferrier MB, Van Den Hout WB, Stiggelbout AM, Frijns JHM. Clinical relevance of quality of life outcome in cochlear implantation in postlingually deafened adults. Otol Neurotol 2008 Monteiro E, Shipp D, Chen J, Nedzelski J, Lin V. Cochlear implantation: a personal and societal economic perspective examining the effects of cochlear implantation on personal income. J Otolaryngol Head Neck Surg 2012.16